Critical Levels

In this episode of Critical Levels, Zach sits down with Dr. Anna-Maria Carvalho, a Royal College–certified emergency physician with a subspecialty in aviation medicine, to unpack what really happens when someone asks, "Is there a medical professional on board?" From the physiology of flying at 36,000 feet to the realities of managing cardiac arrest in a cramped aircraft cabin, this episode tackles the fears, logistics, and practical considerations of in-flight medical emergencies—especially for paramedics, nurses, and physicians who may be called upon to help. ✈️ What We Cover 🫁 The Physiology of Flight Why cabin altitude means we're all mildly hypoxic (normal sats ~92–93%) How hypoxia increases heart rate, blood pressure, and sympathetic tone Why alcohol hits harder in the air Why tomato juice tastes better at altitude The risk of DVTs and who's most vulnerable Barotrauma, ear pain, and when a perforated eardrum can occur 🚨 In-Flight Medical Emergencies Incidence: ~1 in 600 flights Most common categories: Neurologic Cardiac Respiratory Gastrointestinal The realities of flying with chronic disease Why more emergencies are happening as more people travel 🧰 What's in the Emergency Medical Kit? AED (separate from the medical kit) Oxygen & Ambu bag Oral airways (intubation equipment varies by airline) IV supplies (limited fluids, but enough for medication administration) Medications: epinephrine, steroids, bronchodilators, benzodiazepines, antipsychotics, glucose agents, and more BP cuff (palpated pressures only—too noisy to auscultate!) Pulse oximeter (remember: 93% can be normal) 📡 Ground-Based Medical Support Most airlines consult 24/7 emergency physicians on the ground Volunteers don't make diversion decisions—the captain does Diversions involve significant operational and logistical consequences In-flight volunteers are there to assess, stabilize, and communicate 🫀 Cardiac Arrest at 36,000 Feet Move to a bulkhead/galley if possible Call for additional medical volunteers Early AED use CPR until ROSC, exhaustion, or medical futility Diversion decisions are collaborative and situational ⚖️ The Legal Question Good Samaritan protections apply Act within scope No gross negligence or willful misconduct No one has ever been successfully sued for assisting with an in-flight medical emergency You are not responsible for diversion decisions 🕊️ When Death Occurs In Flight Resuscitation attempts may cease when appropriate Diversion is not automatic Flight crew are trained to manage these situations professionally and discreetly 🔑 Key Takeaways You already have the skills. The environment is different—but the fundamentals are the same. Recognizing sick vs. not sick is incredibly valuable. Most in-flight volunteer diagnoses are ultimately confirmed in hospital. About 60% of passengers improve with basic stabilization. You are protected when acting in good faith and within scope. If you've ever hesitated to answer that overhead call, this episode may change your perspective.

On this unique episode, we attend the First60 Toronto Resuscitation Conference and interview several of the speakers. For more detailed information, check out our website, criticallevels.ca

In this episode, Zach sits down with Dr. Ian Drennan and Dr. Sheldon Cheskes to dissect the newly released 2025 AHA and ILCOR resuscitation guidelines. They break down the evidence, controversies, and real-world implications for paramedic practice. Key Topics Covered 🔹 How guidelines are actually created 🔹 Mechanical CPR 🔹 Heads-Up CPR 🔹 IV vs IO Access 🔹 Medications 🔹 Defibrillation Science 🔹 Airway Management 🔹 Post Cardiac Arrest Care  

In this episode, we explore the science, history, and frontline application of End-Tidal CO₂ (ETCO₂) — a tool that offers real-time insight into ventilation, perfusion, and metabolism. Danny and Rance from DnR explain how paramedics can use ETCO₂ to assess and guide care across multiple patient presentations. Key Takeaways: ETCO₂ is the sixth vital sign — reflecting ventilation, perfusion, and metabolism in real time. Capnography vs. Oximetry: SpO₂ shows what was happening; ETCO₂ shows what's happening now. Waveform interpretation: Alpha and beta angles reveal underlying pathology like bronchospasm, obstruction, or air trapping. Clinical uses: Tube confirmation: Real-time verification in 6 breaths or less. CPR: Values <10 mmHg after 20 mins indicate poor prognosis. Ventilation: Real-time feedback for rate and volume. Head injuries: Maintain normocapnia; hyperventilate only during herniation. Sepsis, trauma, PE, and DKA: Trending ETCO₂ helps identify metabolic and perfusion problems. Practical tips: "Filter first, end-tidal to the sky." Inline sensors outperform sidestream for accuracy. End-tidal is not just for intubated patients — use it with nasal prongs for sedation and respiratory monitoring.

Delta Air Crash: Paramedics on the Frontline of a Mass Casualty Incident In this gripping episode of Critical Levels, host Zach Cantor sits down with Ornge Critical Care paramedics Colin and Darren to discuss their response to the February 2025 Delta crash at Toronto's Pearson International Airport. From the initial plume of smoke spotted mid-flight to interagency coordination on the ground, they share how training, adaptability, and teamwork guided decisions under extreme pressure. Key Topics:     •    First impressions from the air and immediate decision-making     •    Mass casualty triage in an unpredictable environment     •    The challenges of communication across multiple agencies     •    The value of leadership, adaptability, and humility under stress     •    Interdisciplinary and interagency debriefs: lessons learned     •    Mental health, recovery, and supporting paramedics after major incidents Takeaway: Mass casualty incidents test every part of the emergency response system. Preparation, communication, and collaboration—not just within one service, but across all responders—make the difference.

What is a paramedic — really? In this thought-provoking episode of Critical Levels, Zach sits down with Dr. Alan Batt to unpack the evolving identity, responsibilities, and future of the paramedic profession. Together, they explore the disconnect between what paramedics are trained for versus what they actually do, the consequences of outdated education models, and the urgent need for professionalization and system-level change. They discuss: Why current training doesn't match real-world workload How we define scope, identity, and autonomy in modern paramedicine The concept of career pathways beyond clinical work What regulatory independence could look like And why it might finally be time for paramedics to "move out of their parents' basement" Whether you're a frontline clinician, educator, leader, or student, this episode challenges assumptions and sparks a critical conversation about the future of paramedicine in Canada and beyond.

Neonates are one of the most feared patient populations in EMS—and for good reason. In this episode, Zach Cantor talks with Anthony Iacolucci, a pediatric respiratory therapist and paramedic, about how to confidently approach neonatal calls. Anthony introduces NEO SECRETS, a practical acronym covering the top 10 causes of neonatal illness, and offers insight into assessment, common pitfalls, and key treatment considerations. NEO SECRETS Breakdown:     •    N – Inborn errors of metabolism     •    E – Electrolyte abnormalities     •    O – Overdose or toxic exposure     •    S – Sepsis (the leading cause of neonatal mortality)     •    E – Endocrine crisis (e.g., hypoglycemia, adrenal insufficiency)     •    C – Cardiac conditions (cyanotic vs. acyanotic presentations)     •    R – Recipe or formula mishaps (e.g., dilution errors leading to hyponatremia)     •    E – Enteric emergencies (e.g., malrotation with volvulus, gastroenteritis)     •    T – Trauma, including accidental and non-accidental injuries     •    S – Seizures (often subtle and hard to recognize in neonates)   Key Takeaways:     •    Neonates are not small adults or even small pediatric patients—they are physiologically distinct and highly vulnerable.     •    Early identification of sepsis, cardiac issues, and metabolic errors can save lives.     •    Paramedics should rely on strong assessment skills, detailed history-taking, and high suspicion for uncommon causes.     •    Videos, glucose checks, pre-ductal saturations, and detailed caregiver interviews are essential field tools.     •    Understanding neonatal physiology, presentation timelines, and risk factors improves both confidence and outcomes.   Why Listen: If you've ever felt unprepared when faced with a neonatal call, this episode provides a clear, practical, and memorable guide to the top threats to neonates—and how to recognize and respond to them in the field.  

In this episode of Critical Levels, we dive into the cutting-edge strategies shaping pre-hospital and emergency department care. Our guests discuss how data-driven decision-making, high-performance CPR, and improved handover processes are revolutionizing patient outcomes. Key Topics Covered: ✅ High-Performance CPR: The role of real-time feedback, mechanical CPR devices, and quality metrics in improving survival rates. ✅ Data-Driven Protocols: How data influences resuscitation techniques, including push-dose epinephrine, early vasopressor administration, and optimizing CPR pauses. ✅ Seamless Transitions of Care: Addressing the challenges of pre-hospital to hospital handover, minimizing interruptions, and ensuring continuity of life-saving interventions. ✅ Training & Coaching: The impact of structured CPR coaching, debriefing sessions, and real-time monitoring in refining paramedic performance. ✅ Future Directions: Exploring nurse-led ACLS, multidisciplinary teamwork, and technology-driven improvements in emergency medicine. Key Takeaways: 🔹 Data analysis is critical in refining protocols and enhancing patient survival. 🔹 Effective communication and structured handovers reduce adverse events. 🔹 Continuous training and feedback loops lead to better resuscitation outcomes. Join us as we explore how collaboration, innovation, and data are shaping the future of emergency medical care.

🔹 Key Topics: 🔸 Why medics need to understand K9 trauma care The overlap between human and canine emergency medicine Common injuries in police, military, and search-and-rescue dogs 🔸 MARCH for Canines—What's Different? The first "M" stands for Muzzle—securing the dog's "weapon" before treatment Understanding the similarities in trauma care between humans and dogs Key differences in how canines respond to injury and shock 🔸 Massive Hemorrhage Control—Why Tourniquets Don't Work on Dogs Anatomical challenges—why dogs' limbs aren't suited for tourniquets When to use direct pressure, wound packing, and hemostatic agents Junctional bleeding—where life-threatening hemorrhages happen in dogs 🔸 Airway & Breathing—Why Intubating a Dog Is Easier Than You Think How to recognize respiratory distress vs. normal panting Why dogs have larger, straighter airways than humans Needle decompression for pneumothorax—landmarks and technique 🔸 Transporting an Injured K9—Avoid These Mistakes Best positions and vehicles for safe transport What paramedics, police, and handlers need to plan for before an emergency 🔸 Shock & Fluid Resuscitation—The Critical Role of Femoral Pulse Checks How to assess perfusion in a dog without a blood pressure cuff Why EZ-IO is the best choice for vascular access in canines When and how to administer fluids, TXA, and blood products 🔸 CPR for Dogs—Does It Work? When CPR can save a dog—and when it won't How to perform chest compressions correctly Naloxone for K9 opioid overdoses—it works, but dosing is different 🔸 Medications & Pain Management—What Paramedics Can Safely Use NSAIDs are dangerous for dogs—avoid them in trauma cases Opioids, TXA, ketamine, and antibiotics—what's safe and effective?

In this episode of Critical Levels, we tackle frostbite with Dr. Maria Doubova, exploring its pathophysiology, symptoms, and treatment. From outdoor enthusiasts to vulnerable populations, frostbite affects diverse groups. Learn about early early recognition and management of frostbite - from mild frostnip to severe cases requiring advanced interventions - and the latest classification system to improve outcomes in this insightful discussion.   What You'll Learn in This Episode:   What frostbite is and who is most at risk. Symptoms and early detection techniques. Frostbite classifications and their significance for prognosis. Practical pre-hospital and hospital management strategies. How frostbite overlaps with hypothermia and what to watch for.

Welcome to the first episode of 2025! This month, we're diving into the critical role of Tranexamic Acid (TXA) in pre-hospital trauma care. Dr. Erik Vu, a critical care flight paramedic, emergency physician, and intensivist, joins us to discuss the latest insights and applications of TXA, particularly in dynamic and tactical environments. From its role in stabilizing clots to its use in mass casualty scenarios, we break down everything you need to know about this cost-effective and life-saving medication. Learn about the benefits of intramuscular (IM) administration, the importance of timely intervention, and how TXA fits into modern trauma care systems. What You'll Learn in This Episode: What TXA is and how it works. The history and research behind its pre-hospital use. Why IM administration is a game-changer in tactical and unpredictable environments. Best practices for dosing and administration. TXA's role in mitigating hemorrhagic shock and improving patient outcomes. Practical tips for integrating TXA into your trauma care toolkit.

On this month's episode, we are going to talk about prehospital blood administration with Dr. Peter Antevy Some topics covered are: Historical trauma management  Blood why  blood components  administration ratios  blood type  Blood administration who do we give blood to medical vs trauma (blunt vs penetrating)  elderly vs peds  vital sign parameters when do we administer it  how do we give it IO vs IV (size matters…) temperature  Logistics how do we get it patient side cold chain storage temperature management  training (initial and ongoing) minimizing waste Challenges consent religion administering to females of child bearing age transfusion reaction Blood Adjuncts  TXA  calcium  other What's the data showing? Next steps 

How prepared do you feel to care for children and youth who have experienced abuse or assault? 1 in 10 Canadians (7.8%) over 15 report at least one instance of sexual abuse before age 15 (Stats Canada) Up to 88% of people being trafficked access health care (Polaris Project) - many don't disclose they are being trafficked Highest rates of intimate partner violence occur between age 12-24 (Stats Canada) Young people aged 15-24 years have the highest rate of sexual assault (Gov't of Canada) In this episode, we will explore the presentation of sexual abuse, sexual assault and sex trafficking in the pediatric setting and discuss trauma and violence informed care practices to guide paramedic care. We will also discuss:  - gaps and barriers to care in this population - practical tips to guide trauma and violence informed care including what not to ask  - role of the Sexual Assault Nurse Examiner and care available in Ontario through the Network of Sexual Assault and Domestic Violence Treatment Centers (SADVTC's)  - mandatory and consent based reporting  - prevelence and risks of strangulation in the context of sexual assault and intimate partner violence and the importance of thorough assessment and imaging  

On this month's episode, we dive deep into the world of military medicine with special forces paramedics, pulling back the veil of secrecy surrounding their vital work. Join us as we explore the unique challenges and high-stakes scenarios these elite medics faced on the front lines. From advanced trauma care in combat zones to the mental resilience required for their demanding roles, our guests share their incredible experiences and insights. What is CANSOFCOM/JTF 2? What is your role within the team? What does training look like? Medical vs trauma treatment TCCC MARCHE management  Blood Challenges of providing austere medicine  Attributes of a great SOF medic Equipment selection  Mindset/attitude/standards Relationship building

On this month's episode, we're joined by Dr. Justin Mausz to discuss violence against paramedics.  During the episode, you'll hear us cover: How often are we seeing violence against paramedics What is violence? Is it different from harassment? Does intent matter?  Incident reporting How does it compare to other industries? What does violence against paramedics look like? How do we balance paramedic and patient safety? What do we do with this? PPE Policy development  External vs internal violence The value of research

On this month's episode, we're joined by Dr. Steven Sanders to discuss heat related illnesses.  During the episode, you'll hear us cover: Health impacts of temperature increase  Physics/physiology of temperature vs heat Spectrum of heat related illness heat rash heat cramps heat edema heat syncope heat exhaustion  heat stroke exertional vs classic Comorbidities/confounders/risk factors Temperature assessment Disease management & treatment

On this month's episode, we're joined by Dr. Bonnie Snyder to discuss BVM as well her recently published paper in Resuscitation: Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest.    During the episode, you'll hear us cover:   There is nothing basic about the BVM - it is not a benign intervention Rate and volume based on the guidelines  Consequences of excessive rate/volume Consequences of under ventilation  General airway management positioning  suction airway adjuncts mask seal C-E technique 2 person technique  waveform capnography and other real time feedback importance of proper volume importance of proper pressure  BVM sizing  Dr. Snyder's study  research question/impetus P-I-C-O results feedback  next steps

On this month's episode, we're joined by Dr. Katie Lin to discuss TBI and the crashing brain.    During the episode, you'll hear us cover:   head injury differentials and history gathering  ischemic vs hemorrhagic  head injury etiology  head injury pathophysiology  assessment 3 step neuro exam  pupil assessments  signs/symptoms of herniation  ECG changes management  avoid/manage the H bombs (hypoxia, hypotension, hyperventilation) airway management  ICP management  other medications  seizure management  paediatrics  neuroprognostication 

On this month's episode, we're joined by Dr. Janice Tijssen to discuss pediatric cardiac arrest. During the episode, you'll hear us cover: The importance of our early interventions What is cardiac arrest incidence/epidemiology etiology  risk factors/past medical history outcomes sociodemographics Differences between adult and pediatric cardiac arrest Simplifying our response Symptomatic bradycardia The importance of scene time The importance of CPR/ventilation IV vs IO, SGA vs ETT Epinephrine   PRIME study Family presence during arrest  Disposition

On this month's episode, we're joined by Dr. Louisa Marion-Bellemare to discuss Suboxone (buprenorphine/naloxone) and managing patients who use illicit and controlled drugs. During the episode, you'll hear us cover: history of the drug crisis  lay of the land of the current drug crisis historical treatments opiate pharmacology  healthcare utilization  stigma  suboxone use  patient advocacy